Marina Gorbis's Blog, page 772

Precision Medicine Could Have a Major Impact on Healthcare Outcomes and Costs - SPONSOR CONTENT FROM SIEMENS HEALTHINEERS

The transformation of health care continues at a rapid pace, bringing opportunities and challenges for health care providers to deliver improved clinical outcomes at lower costs.

Despite the tidal wave of medical knowledge and digital capabilities, widespread unwarranted variations in clinical practice drive higher costs and result in poorer quality. And many health care systems continue to struggle to reliably deliver evidence-based care.

While progress is clearly being made, as an industry, we still have far to go to consistently deliver on the promise of high-value care through technology and innovation.

In a recent report from Harvard Business Review Analytic Services, experts analyzed how expanding precision medicine offers health care providers new opportunities to provide high-value care. Their conclusion: the expansion of precision medicine could have a major impact on outcomes and costs.

Why Medicine Needs to Become More Precise

The precision medicine initiative is widely viewed as a way to improve health care because it focuses on diagnosing and treating each individual patient based on his or her genetic characteristics. Some in the medical community believe that definition should be expanded.

“While precision medicine can be seen by some people as genomics-guided treatment, I think this definition is too limiting,” says Dr. Larry Chu, a Stanford professor who advised President Barack Obama on the Precision Medicine Initiative announced in 2015. “I think precision medicine means precisely diagnosing conditions, then integrating all relevant patient data and insights to guide care to the best outcomes. It is about providing the right treatment to the right patient at the right time.”

In the report, the experts agreed that the practice of precision medicine will grow because the benefits to health care organizations, providers, and patients in the form of better outcomes and reduced costs are simply too great to pass up. Research suggests that eliminating unwarranted variations in medical care can reduce the cost of patient management by at least 35 percent.

But while precision medicine is already extending lives and improving the quality of patients’ lives, the experts believe there is much to be done to expand its use. That will require executives of health care providers and the entire medical community to embrace, at scale, four pillars of care. These can be grouped into two broad categories: precision diagnosis and individualized therapy.

Precision Diagnosis

Pillar 1: Improve Diagnostic Accuracy

Improve the accuracy of each diagnosis by treating diagnosis not as a singular event but rather as a precise and systematic process enabled by integrated imaging and laboratory results. Speed, quantification, and accuracy are critical because the diagnosis determines the subsequent path of care for each patient. Leverage technology to allow diagnoses to be made, in many cases, at the initial point of care.

A crucial first step in expanding precision medicine is to improve diagnostic accuracy. As Harvard Business School professor Clayton M. Christensen and venture capitalist Spencer Nam, a senior research fellow at the Clayton Christensen Institute, wrote in Harvard Health Policy Review, “Precisely understanding the causes and progression of a disease is the fastest and the most economical way to deliver more effective and individualized therapies to each person.”

Pillar 2: Reduce Unwarranted Variations in Diagnoses

Tightly align training, systems, and protocols throughout the medical community to ensure more consistent care and diagnoses, eliminating variations related to the type of imaging or testing performed, who performed it, or who read the results. The goal is to provide consistent medicine, based on evidence, for the patient’s specific medical condition.

Individualized Therapy

Pillar 3: Personalize Care When It Matters

Move beyond treating patients based on which genetic subgroups they fall into, and treat them instead as distinct individuals, taking full advantage of our understanding of each patient’s unique genetic and metabolic makeup—along with the images and lab test results collected over the course of a patient’s treatment. This enables earlier intervention in cases involving patients who do not respond to treatment.

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Pillar 4: Utilize Advanced Therapies

Take advantage of robotics and advanced imaging technology to make greater use of minimally invasive procedures, especially where imaging can be deployed in real time to guide the procedure and thereby optimize its effectiveness, minimize errors, and reduce costs.

By committing to expanding the concept of precision medicine in this fashion, health care providers have a real opportunity to resolve their biggest challenges.

CEOs of health care institutions, who are under increasing pressure to improve patient outcomes and simultaneously reduce costs, have every incentive to embrace these four pillars of care and expand precision medicine not only within their own organizations but also throughout the health care community.

At Siemens Healthineers, we believe health care is on the cusp of realizing the benefits of precision medicine – and this has already been demonstrated by many real-world examples from across the entire health care spectrum.

Download the HBR white paper on the Siemens website.

 

 

 

 

 

 

 

Making U.S. Fire Departments More Diverse and Inclusive

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Picture a typical firefighter. Who comes to mind? If you imagined a white man, that’s understandable: 96% of U.S. career firefighters are men, and 82% are white. This homogeneity is striking, especially when you compare it to the U.S. military, which is 85% men and 60% white, and local police forces, which are 88% men and 73% white.

Many fire departments recognize that their lack of diversity as a problem and say they’re committed to increasing racial and gender diversity. “We have to diversify, because it actually improves our organization. It helps us address the needs of the public better,” says Derek Alkonis, the Los Angeles County Fire Department (LACoFD) assistant chief.  Ralph Terrazas, chief of the Los Angeles City Fire Department (LAFD), agrees:  “[We] will provide a higher level of service to the communities we serve when the people of that department respect the culture, language and beliefs of the people within that community.”

But what’s the actual path for departments achieving more diversity? And if they do so, will their members embrace how it improves their organization?

Answering these questions requires a closer look at two factors: what firefighters’ work actually consists of and what departments are currently doing to address diversity in their ranks. The answers suggest we need a new model for leaders.

What firefighters actually do.

Yes, they’re fighting fires, which requires climbing ladders, hauling hoses, and carrying victims from burning buildings. But this is only a small subset of the job. In 2016, only 4% of emergency calls to which U.S. fire departments responded were actually fires. The majority (64%) were medical emergencies.

To succeed as a firefighter, stereotypically masculine traits like brawn and courage are simply not enough. Firefighters also need the intellectual, social, and emotional skills required to deliver medical emergency aid, support each other through traumatic experiences, and engage intimately with the communities they serve. In short, successful firefighters embody a complex mix of skills and traits. And yet, in my research on reducing gender bias and my work conducting training on general diversity and inclusion with fire departments, I find that, when evaluating fit and competence, firefighters tend to default to a reductive set of traits (physical strength evaluated through strict fitness tests, for example) that serve to maintain white men’s dominance in the fire service.

This manifests itself in several ways. A common sentiment I’ve heard many times is, “I don’t care if you’re black, white, female, male, or polka-dot. All I care about is if you can do the job.” But if this performance-based meritocracy were true, getting the job done would encompass a variety of skills and talents at which both men and women and people of all races and ethnicities could potentially excel. However, as Felix Danbold and I explain in our forthcoming research in Organization Science on gender bias in the fire service, “when the topic of female firefighters came up, the importance of physical strength was consistently and spontaneously invoked to justify the relative absence of women in the fire service, but the importance of compassion (a female-stereotyped trait) was rarely, if ever, brought up to argue for bringing more women into the profession.”

We determined that this is because stereotypes about women’s relative lack of physical strength and stamina have led to a widespread belief that departments have lowered their standards to accommodate female firefighters, thus undermining the integrity of the service and posing a threat to their colleagues and communities.

While many women firefighters do have the physical abilities to succeed as firefighters, those who are or have been a part of the LAFD and LACoFD have nonetheless experienced excessive, unrelenting scrutiny and skepticism since being accepted into the ranks in 1983.  We heard comments like “I have to prove myself on every call, every time” and “Everyone expects you to fail.” Women, more than men, reported being repeatedly drilled on the most physically-demanding tasks every time they were assigned to work with a new crew, no matter how many years of experience they had. One male Battalion Chief told us about a recent experience when a woman was assigned to his crew, and all five of the other men on the crew requested transfers the next day.

Black firefighters also have to compensate for stereotyped assumptions of inferior competence. Historically, this was especially true during departments’ legally mandated affirmative action hiring periods. “When I was hired,” said Brent Burton, LACoFD Captain, Recruitment Unit and former president of the Stentorians (the recognized employee group for black firefighters), “people essentially told me ‘you’re an affirmative action guy, you’re not as good.’”  Today, greater representation has reduced some of that performance skepticism, but black firefighters still face challenges with social exclusion and explicit racism.

The fire service’s challenges with diversity go beyond gender and race. Openly gay men are exceedingly rare in the fire service; the few who are out of the closet face severe social exclusion. Cameron Langhans, LAFD Captain I and Paramedic explains, “when I was married to a woman, I had the privilege of being seen as a straight, white man, and I felt the automatic inclusion that comes with those identifiers. Now that I have identified as gay, I have to prove myself all over again.”

Ultimately, most firefighters who are not heterosexual white men must be extremely resilient to overcome relentless scrutiny and exclusion in their careers.

What’s being done to increase diversity?

Many departments and industry groups are proactively trying to diversify and to change their culture to be more inclusive, particularly with respect to recruitment and promotion processes. In the mid-1990s, for example, the Stentorians created a promotion preparation program for its members to offset the insufficient mentoring black firefighters received in the field. “This is one reason why there is relatively equal representation of blacks throughout ranks of the LAFD” compared to the population of Los Angeles County, says LAFD Assistant Chief and former Stentorians’ president Kwame Cooper.

More recently, the LAFD and LACoFD, along with the LA Women in the Fire Service (LAWFS), the local industry group for women, have hosted events to help educate and prepare prospective female firefighters. “We identify women who passed the physical and written entrance tests and are now in the pool of qualified candidates who are waiting to be hired,” says Captain Burton. “Then we have our current women firefighters showing these interested women what the job is really like, and what they need to do to succeed.”

Throughout California, the departments that have most effectively leveraged these kinds of outreach efforts “integrate recruitment and mentoring of women and people of color into subsequent stages of the hiring process,” explains Dave Gillotte, LACoFD Captain and President of the Firefighters IAFF Local 1014. That means, for example, targeting qualified candidates from underrepresented groups to advance through the selection process. This differs from the more traditional method of relying on a random lottery from the general candidate pool, a place where women and people of color are underrepresented and thus have lower odds of being selected.

Together, these important efforts expose members of underrepresented groups to careers in the fire service and gives them helpful training and mentorship opportunities. Many of those who make it on to become firefighters also find a sense of community among members of their own underrepresented groups in organizations like the LAWFS and the Stentorians.

The problem is that none of these programs directly address the challenge of inclusion—that is, of being valued and having a sense of belonging, regardless of who you are. So how can we get more firefighters to recognize members of non-prototypical groups as being equally capable of success in the fire service?

Reframing the firefighter prototype

In my forthcoming research with Felix Danbold, we find that reframing the professional prototype of what it means to be a firefighter to emphasize the importance of legitimate, stereotypically feminine traits, like compassion, has promising effects on creating a more inclusive environment for women.

We had active-duty firefighters and members of the general public watch videos of a white, male fire captain describing the most important traits of a successful modern firefighter. When he listed compassion first, followed by team orientation and physical strength, viewers’ perceptions of female firefighters’ abilities and support for gender diversification policies were much more positive then they were when they watched him present those same traits in reverse order.

This, we believe, is a promising first step in increasing the perception of professional fit of underrepresented or undervalued groups. And we’re starting to learn more about how the research can extend to practice in the form of a general diversity and inclusion training program I developed for fire department leaders that includes education on how biases and stereotypes affect the experiences of firefighters from underrepresented groups. While not revolutionary, these steps are vital. “Biases impact how we think and the decisions we make; we should be aware that they exist and how we manage them,” says LACoFD fire chief Daryl Osby.

To minimize the potential effect of biases, fire service leaders need to convey transparent, consistent expectations and evaluation processes for establishing members’ competence and trustworthiness. For instance, I coach fire captains to not only pre-determine the appropriate drills that all new crew members need to perform, but also how many times each task must be done correctly to be deemed acceptable. This can reduce the risk of shifting standards being applied to people from underrepresented groups about whom there is skepticism.

I also encourage leaders to elevate the value of skills that align with stereotypes about women and minorities through concrete actions. For example, to promote the social and emotional strengths commonly associated with women, one might look for ways to acknowledge and celebrate crew members who demonstrate what we call the “heart and soul” of a firefighter in the station and out in the field. Joviality — defined as “markedly good humor” and one that helps process emotional trauma — is a positive trait associated with black Americans somewhat more than with white Americans, so explaining that a jovial culture can increase crew effectiveness may reduce some of the skepticism about and exclusion of black firefighters. When you hold all department members accountable to excellence along the full spectrum of traits associated with being a successful firefighter, you help firefighters that don’t fit the straight, white, male archetype and create more equal opportunities and inclusion.

To measure the effectiveness of this approach, I surveyed 138 chief officers and 1,096 of their subordinates in the LACoFD before training the chiefs, then followed up with 93 of the chiefs and 1,347 of their subordinates two months later. I found that, after this intervention, chiefs’ were spending more time mentoring team members on social and emotional skills, more strongly endorsed diversity and inclusion, and supported policies to increase representation of women. More compellingly, the subordinates evaluated their chief officers as better leaders following the training. They reported respecting their supervisors more, seeing them as better role models and mentors, and believing that they were more accepting of differences.

However, as L.A. Fire Commissioner Rebecca Ninberg notes, “changing the culture requires a long-term commitment to integrate it into the DNA of the department.” Thus, leadership training is only a first step; real change starts when leaders employ what they learned every single day. “Diversity goal messaging from the fire chief, consistent training, engagement of key department stakeholder groups, and the use of ongoing measurements of progress” are critical, says LAFD Fire Chief Terrazas. This helps the inclusive firefighter prototype spread through the ranks.

Most firefighters are probably unaware of how their status-quo perceptions about their profession reinforce bias and create unequal opportunities for peers from underrepresented groups. My research points to a more inclusive alternative. Hopefully, the departments that have implemented my training approach with will see continued improvement in their efforts to confront the diversity challenges of the fire service, and will serve as examples to others across the country, as well as different types of organizations that would like to become more meaningfully diverse. Perhaps most importantly, it will make a difference in the careers of talented and hardworking firefighters.

Don’t Give Up on a Great Idea Just Because It Seems Obvious

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I spent eight years failing to act on an innovative idea that I knew would work. It was an idea that had not just technological promise but also societal value. It would help people contribute to the most important, impactful charities in the country. But I kept letting it languish.

The biggest reason I held back wasn’t fear, being too busy or lazy, or any of the other natural blockades to entrepreneurship. It was something else.

I didn’t move on this idea because it seemed obvious. It made so much sense to me that I was convinced someone else would do it. So, I assumed it would be a waste of time and energy for me.

I was wrong. And it turns out I would have known better if I had listened to some of the best-known innovators, including Isaac Asimov and Steve Jobs. Obviousness, it turns out, is a common — and even important — part of the creative process. Whether you’re considering the possibility of launching a startup or you want to create change within your organization, learn from my experience. Don’t procrastinate like I did.

For years, I organized charity fundraisers at bars. I’d gather friends together, discuss a cause and present information about an organization helping that cause. I’d show photos, tell stories, and explain how each charity helped.

These crowds included young investment bankers, who often agreed to contribute $500 or $1,000. I’d thank them and ask if they had a check. They’d respond, “A check? No, I’m 25. I don’t use checks.” So, I’d explain that they could contribute to the charity via its website. Asking them to surf to a website on their mobile phones at the bar just didn’t work. Many would say they’d take care of it at home sometime, from a computer. But, despite the best of intentions, most didn’t. The only contributions I’d end up with from these events were in cash, usually a few hundred dollars total in $20 bills from whoever had extra cash on them.

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Meanwhile, when the bar tab would come at these same events, we’d split it by paying each other through our apps, such as Venmo. That’s when I realized there should be a simple app that allows people to contribute to any U.S. charity.

See? Obvious. So even though I knew I could gather a team to build such a tool, I figured someone else would do it. I let that assumption hold me back. Instead, I should have taken the sense of obviousness as a reason to move forward with the idea.

“When you ask creative people how they did something, they feel a little guilty because they didn’t really do it, they just saw something. It seemed obvious to them after a while,” Steve Jobs told Wired in 1996. “That’s because they were able to connect experiences they’ve had and synthesize new things.”

Back in 1959, Isaac Asimov wrote about how this same idea applied to “the theory of evolution by natural selection, independently created by Charles Darwin and Alfred Wallace.” Both men had traveled, observing the diversity of plant and animal life. Both read Malthus’s Essay on Population and realized how the latter may help explain the former. “Once the cross-connection is made, it becomes obvious,” Asimov wrote. He noted that biologist Thomas H. Huxley “is supposed to have exclaimed after reading On the Origin of Species, ‘How stupid of me not to have thought of this.’”

A paper from the University of Minnesota argues that the recognition of obviousness is an important part of one of the “five stages of the creative process.”

“In times of clarity, your resolutions appear obvious and simple; but in fact, they appear simple because the illumination has all the parts lining up and shedding light on a resolve,” the paper says.

But there’s also a flip side to this. “Obvious” answers aren’t obvious to most people, partly because most people aren’t thinking about the question.

Ideas only come to those who recognize a problem and look for innovative solutions. As the book How to Think Like Einstein explains, “Even Einstein couldn’t find a solution if he had the wrong problem. You must have an enabling problem, one that allows imaginative solutions different from your original expectations…Finding that great problem requires much thought, especially when the solution seems obvious.”

In the end, I did pursue my idea, co-founding Givz. And this experience helped prepare me for some of the feedback we get from partners and stakeholders. Recently, I found myself having to assuage a representative from a corporation and explain that the idea really is as simple as it sounds.

“Really?” he said. “Then that’s a no-brainer.”

Exactly.

Why Trump and Xi’s 90-Day Trade Truce Is a Step in the Right Direction

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The audible, global sigh of relief in the wake of last weekend’s decision by Presidents Donald Trump and Xi Jinping to negotiate trade war issues over the next 90 days was well justified. The deal is a big step forward for all concerned.

Let’s quickly dispense with the scoffing critique voiced by several professional doubters that little can be accomplished in 90 days and that the agreement therefore is nothing more than an arrangement to kick the can down the road. While it is true that a comprehensive deal is very unlikely to be completed in the next 90 days, it should be obvious that presidents who can agree to talk for the next 90 days can also agree to talk longer if the first 90 days seem to augur something promising. If they don’t, then it probably makes sense to shut the talks down — and at least it will then be clear that we didn’t move rashly ahead to impose massive tariffs without giving negotiations an honest try and will garner more domestic and international support for some form of further trade actions if talks fail.

Indeed, this was the only sensible alternative. It was clear that the Chinese were not immediately going to yield to American requests, and it was equally clear that imposing American sanctions without any further effort at negotiation was likely to be counterproductive.

A second important step forward was the clear designation by President Trump of U.S. Trade Representative Robert Lighthizer as the key leader of the U.S. negotiating team. Because he is known to be a knowledgeable and tough negotiator, the Chinese have tried over the past two years to drive discussions through Treasury Secretary Steve Mnuchin and National Economic Council Advisor Larry Kudlow. These two were perceived to be softer, less knowledgeable, more pro-globalization, and more concerned about financial markets than Lighthizer. By specifically pointing to the trade representative as the guy in charge (as his title indicates he should be), Trump made it clear that the United States is serious. Lighthizer knows the World Trade Organization (WTO) and the global trade rules upside down and backward. He is a leading strategist and a seasoned negotiator who knows all the key global players as well as where all the bodies are buried. He won’t be deceived, and he will demand concrete, measurable results.

One of the most interesting statements to come out of the Buenos Aires dinner was President Xi’s comment that Qualcomm’s offer to acquire NXP Semiconductors might now be approved if it were to be proposed again. Qualcomm scrapped the deal in July after the Chinese antitrust regulator didn’t make a ruling by the deadline for consummating the deal. In other words, the Chinese government’s objection had been political rather than legal all along.

Qualcomm quickly stated that there would be no new proposal. But the important point here is that the main U.S. complaint about China’s trade/globalization policies is precisely that Chinese trade and industrial policies are political and lead to government intervention in markets that contradicts China’s stated commitments to the spirit and rules of the WTO and to market-oriented globalization.

This issue is not new to veterans (like Lighthizer) of the U.S.-Japan and U.S.-South Korea trade negotiations of the 1980s and 1990s. The heart of the problems in these cases was the commitment of these countries to equaling and surpassing the capabilities of the United States in targeted industries such as chemicals, steel, autos, semiconductors, aircraft, computers, machine tools, biotech, ship building, and computers. These governments intervened in markets to provide investment guarantees, trade and R&D subsidies, dedicated government procurement, and trade protection, including “buy national” policies.

China has been a careful student of the Japanese and South Korean strategies as well as of those of Taiwan and Singapore. It has adopted the key elements of each and then added its own. Particularly significant has been China’s approach to foreign investment. While Japan, South Korea, and Taiwan largely eschewed foreign investment, China has welcomed and promoted it. But, of course, it has done so on its own terms. So foreign investors have often been required to enter joint ventures and to transfer technology as a condition of being allowed to invest. They were required to export a certain proportion of their production and subject to extensive theft of their intellectual property.

Even in the cases of Japan and South Korea, it was always difficult for foreign companies to have their complaints heard. The biggest problem was that government bureaucrats had extensive informal power. They could wink or nod at corporate leaders and the complaints would be buried. Or they could wink and nod and distributors would suddenly no longer buy foreign products for distribution. They could also impose new testing standards or ignore requests for testing. There were a hundred ways in which the bureaucracy could quietly carve up a company, and the company would have no effective recourse. In China, this situation is even more difficult. There is what is known as the “death of a thousand cuts.” A company may find itself wounded and not have any idea of the source of the cut.

Lighthizer’s task will be to find a way to compel China’s policymakers and bureaucrats to minimize intervention and to conform to the spirit as well as the letter of the WTO’s rules and of the broader free-trade doctrine to which they aver they are dedicated.

It will be no easy task. Lighthizer deserves the support and good wishes or all who hope for a friendly resolution of U.S.-China differences and for the continued success of globalization.

Why Social Entrepreneurs Are So Burned Out

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Can entrepreneurs help address the society’s biggest challenges — without burning out?

These are pressing questions. According to Deloitte, private businesses are increasingly expected to help solve the most challenging social problems of our times — health, poverty, and the promotion of sustainable development — in the absence of, or in conjunction with, government action. And many are eager to step into this role: the consultancy’s recent survey of more than 11,000 business and HR leaders worldwide found that almost 80% say “citizenship and social impact” is very important or important today.

But is it reasonable to expect a for-profit enterprise, and its employees, to address large-scale social problems? Helping those most in need and running a commercially viable business at the same time can create conflicting of goals. Our research, which explores how this conflict manifests itself in the lives of entrepreneurs working within for-profit companies, provides the first robust evidence that it can have serious repercussions for their health and wellbeing.

We based our study on original longitudinal survey data gathered from employees and entrepreneurs in the United Kingdom. We recruited 1,388 respondents from among 3,525 employees selected randomly from a representative database of the British working age population — a response rate of 39%. This sample was made up of 25% entrepreneurs and 75% employees. Our research focused on the entrepreneur subsample, and we collected over three waves of survey data from this group administered at two-month intervals. We asked questions about prosocial motivation and the desire to help others to gauge the extent to which individual entrepreneurs had such tendencies and interests. We also asked about their ability to control and cope with important things in their lives, and whether they ever felt that difficulties were piling up so high that they could not overcome them. We analyzed the data using statistical techniques that allowed us to identify the causal structure of how the pursuit of social objectives causes stress and ultimately affects health and wellbeing.

Our analysis revealed that, generally, stress is a significant problem for social entrepreneurs. When trying to achieve commercial goals and give back to the community at the same time, these entrepreneurs are likely to overload themselves with too many responsibilities and, consequently, deplete their personal resources. The cost of resource depletion can include reduced time with family and poor sleep quality.

However, we found that social entrepreneurs who enjoy a high degree of autonomy at work are less inclined to experience the same levels of stress. When these entrepreneurs can organize their business so they have control over how, where, and when they help others, they are better able to manage any work overload and stress levels. This autonomy is critical for entrepreneurs to create social impact without their mental and physical health plummeting, but is absent in the lives of many in our study. Specifically, new or smaller enterprises often find themselves dependent on a single client whose organizational procedures dictate when, where, and how entrepreneurs work.

The big question is: Can we help all social entrepreneurs safeguard their autonomy and reduce their stress levels to a manageable level? And how? The answer is important because, even as we recognize the importance of of social enterprises in today’s business world, we might be be encouraging entrepreneurs to jeopardize their health.

While our research doesn’t yet explore which specific interventions might be most helpful for preventing burnout, we do know that leaders promoting social entrepreneurship initiatives within should be aware of possible adverse personal consequences for their employees. They should also help entrepreneurs organize their work to permit personal autonomy whenever possible. Social enterprises cannot continue to deliver sustainable impacts if the people running them are exhausted.

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The Coalitions That Could Hold the EU Together

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The European Union has experienced a series of disasters over the last 10 years, each one of which has posed a major threat to its stability. First, there was the fallout from the 2008-9 financial crisis and the arguably ill-judged imposition of austerity on the Union’s southern members. Combined with the migration crisis, this encouraged the rise of populist anti-EU movements.  And then, there was the British vote to leave the EU altogether.

That the EU remains largely intact amidst all this is due in no small part to Germany. Under Chancellor Angela Merkel, Germany has at times been willing to bear a disproportionate burden of the costs of crisis management. It has carried out what economist Charles Kindleberger once memorably described as the “bribery and arm twisting” necessary to keep alliances such as the EU afloat. And although it has not always been able to mobilize support among other member states for its position (for instance in  the refugee crisis), it has, to a certain extent, been Europe’s hegemon, an ancient Greek term designating the dominant member of an alliance or confederation.

Unfortunately, it’s a role that Germany has had increasingly to shoulder alone – and that, as I argue in my recently published book, is unsustainable. As a “first among equals” Germany lacks the dominance or magnitude of advantage that typically exists in hegemonic relationships. Its traditional partner at the EU’s helm, France, has struggled with its own economic problems since 2008 and has taken a back seat in driving EU policy. And even before the Brexit vote, Britain, the EU’s second largest economy, had detached itself from the EU’s inner circle by remaining outside the Eurozone and out of the region of borderless travel known as the Schengen Area.

What’s more, Germany’s reluctance to alleviate the pain of economically-strapped member states aggravated rather than eased the Eurozone crisis, which was ultimately managed by the ECB rather than by Germany. And Germany’s failure to consult on migration policy resulted in a number of other EU member states resisting demands to follow its stance during the refugee crisis. Overall, it cannot subordinate its own needs to the group’s needs to the extent necessary for a hegemon to retain its partners’ allegiances.

This means that if the EU is to survive the onset of a new crisis (or the flare up of an existing one) it will need stronger, more inclusive leadership than Germany has provided on its own. Given the absence of a single European country large enough to take on the role of hegemon on its own, it is likely two or more countries will need to come together to form a hegemonic coalition. There are three conceivable options:

A revived Franco German coalition

The resurrection of the EU’s traditional leadership constellation is politically feasible given the election of the Emmanuel Macron as French president in 2017 and the return of the Grand Coalition of German political parties in 2018. Franco-German cooperation can still be a powerful magnetic force in the EU and a bilateral Franco-German bargain can often provide a template for a larger Union agreement. This time around, however, it is likely the traditional roles would be reversed, with Paris looking to accelerate the speed of change, and Germany seeking to slow it down, particularly among those initiatives aimed at raising the volume of financial transfers between Eurozone member states.

A Weimar Coalition

While a rejuvenated Franco-German coalition appears obvious, it may not have the influence to mobilize Central and Eastern European member states, given the vast gap between their vision and that of the Polish and Hungarian governments in particular. An expanded coalition that includes Poland, a nominal partner of France and Germany in the “Weimar Triangle” founded after the end of the Cold War, could have greater legitimacy. However as long as the conservative and Eurosceptic Law and Justice Party remains in office in Poland, such a coalition will not materialize.

A new Hanseatic Coalition

The third conceivable coalition is named after the medieval association of trading cities stretching from the Netherlands in the west to the Baltic Sea in the east. This coalition would include Germany and the eight northern European member states whose finance ministers began to meet in early 2018 to discuss reforming the Eurozone. On monetary, fiscal, and EU budget policies these states are closer to Germany than Germany is to France. However, given their geographical and ideological positions it is unlikely they could integrate and mobilize the support of Southern, Central, and Eastern European members or that Germany would weaken its relationship with France in their favor.

An uncertain future

Whatever its make-up, any new hegemonic coalition will face an uncertain task. The nationalist and Eurosceptic trend which began in the 1990s and gained momentum during the recent refugee crisis amid public opposition to mass integration and long-standing fears about dilution of national identity and globalism, has crystallized into a major political force.

Across Europe, nationalist Eurosceptic parties have made significant electoral gains, in some cases taking office, in others becoming the main voice of the opposition, forcing centrist leaders to adapt their policies to win back conservative votes.  Although there remains strong resistance to far-right parties, as evidenced by Macron’s victory, support in France for the right-wing National Front party is higher than ever. If President Macron fails in his efforts to reform and rejuvenate the French economy, as he well might, the extreme Right is well-placed to benefit from his failure.

The situation in Germany is similar. Last year, the AfD became the first extreme right-wing Eurosceptic party to win seats in Germany’s federal parliament since 1953. Having won 12.6% of the vote, it is now the country’s biggest opposition party putting pressure on center right parties to accommodate Eurosceptic opinions.

Particularly in the wake of Brexit, Europe needs a new champion and without strong support from a politically dominant hegemon or hegemonic coalition, the risk that the Union will fall apart in new crises is very real. And we don’t have much time left for stabilizing hegemonic leadership to develop. Right now, there is a two-to-four-year window – at most – before the next French and German elections. If these countries’ current leaders do not take the opportunity to weld Europe more closely together, then the next big crisis may well signal the beginning of the end to the nearly 70-year-old project that has kept the peace in Western Europe, fostered its democracies, and helped to deliver growth and prosperity by keeping European countries’ economies and societies open to each other.

Why Companies That Wait to Adopt AI May Never Catch Up

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While some companies — most large banks, Ford and GM, Pfizer, and virtually all tech firms — are aggressively adopting artificial intelligence, many are not. Instead they are waiting for the technology to mature and for expertise in AI to become more widely available. They are planning to be “fast followers” — a strategy that has worked with most information technologies.

We think this is a bad idea. It’s true that some technologies need further development, but some (like traditional machine learning) are quite mature and have been available in some form for decades. Even more recent technologies like deep learning are based on research that took place in the 1980s. New research is being conducted all the time, but the mathematical and statistical foundations of current AI are well established.

System Development Time

Beyond the technical maturity issue, there are several other problems with the idea that companies will be able to adopt quickly once technologies are more capable. First, there is the time required to develop AI systems. Such systems will probably add little value to your business if they are completely generic, so time is required to tailor and configure them to your business and the specific knowledge domain within it. If the AI you are adopting employs machine learning, you will have to round up a substantial amount of training data. If it manipulates language — as in natural language processing applications — it can be even more difficult to get systems up and running. There is a lot of taxonomy and local knowledge that needs to be incorporated into the AI system —similar to the old “knowledge engineering” activity for expert systems. AI of this type is not just a software coding problem; it is a knowledge coding problem. It takes time to discover, disambiguate, and deploy knowledge.

Particularly if your knowledge domain has not already been modeled by your vendor or consultant, it will typically require many months to architect. This is particularly true for complex knowledge domains. For example, Memorial Sloan Kettering Cancer Center has been working with IBM to use Watson to treat certain forms of cancer for over six years, and the system still isn’t ready for broad use despite availability of high-quality talent in cancer care and AI. There are several domains and business problems for which the requisite knowledge engineering is available. However, it still needs to be manipulated to a company’s specific business context.

Integration Time

Even once your systems have been built, there is the issue of integrating AI systems into your organization. Unless you are employing some AI capabilities that are embedded within existing packaged application systems that your company already uses (e.g., Salesforce Einstein features within your CRM system) the fit with your business processes and IT architecture will require significant planning and time for adaptation. The transition from pilots and prototypes to production systems for AI can be difficult and time-consuming.

Even if your organization is skilled at moving pilots and prototypes into production, you will also have to re-engineer the business processes to have full impact on your business and industry. In most cases AI supports individual tasks and not entire business processes, so you will have redesign business processes and new human tasks around it. If you want to affect customer engagement, for example, you will need to develop or adapt multiple AI applications and tasks that relate to different aspects of marketing, sales, and service relationships.

Human Interactions with AI Time

Finally, there are the human challenges of AI to overcome. Very few AI systems are fully autonomous, but are rather focused on augmentation of and by human workers. New AI systems typically mean new roles and skills for the humans who work alongside them, and it will typically require considerable time to retrain workers on the new process and system. For example, investment advice companies providing “robo-advice” to their customers have often attempted to get human advisors to shift their focus to “behavioral finance,” or providing advice and “nudges” to encourage wise decisions and actions in investing. But this sort of skill is quite different from providing advice about what stocks and bonds to buy, and will take some time to inculcate.

Even if the goal for an AI system is to be fully autonomous, it is likely that some period of time in augmentation mode will be necessary. During this period, a critical piece of machine learning occurs through interaction between the system and its human users and observers. Called interaction learning, this is a critical step for organizations to understand how the system interacts with its ecosystem. They can often gather new data sets and begin to bake them into algorithms during this period — which often takes months or years.

Governance Time for AI Applications

While AI systems are geared to provide exponential scale and predictions, they will need a much broader governing approach than the classic controls and testing driven approach. The efficacy of AI algorithms decays over time because these are built based on historical data and recent business knowledge. The algorithms can be updated as the machine learns from patterns in new data, but they will need to be monitored by subject matter experts to ensure the machine is interpreting the change in business context correctly. Algorithms will also have to be continuously monitored for bias. For instance, if an AI system is trained to create product recommendations based on customer demographics and the demographics change dramatically in new data, it may provide biased recommendations.

Governance will also include watching for customer fraud. As the systems become smart so will the users. They may try to game the systems with fraudulent data and activities. Monitoring and preventing this will require sophisticated instrumentation and human monitoring in the context of your business.

Winners Take All

It may, then, take a long time to develop and fully implement AI systems, and there are few if any shortcuts to the necessary steps. Once they have been successfully undertaken, scaling —particularly if the company has a plentiful supply of data and the knowledge engineering mastered— can be very rapid. By the time a late adopter has done all the necessary preparation, earlier adopters will have taken considerable market share — they’ll be able to operate at substantially lower costs with better performance. In short, the winners may take all and late adopters may never catch up. Think, for example, of the learning and capability that a company like Pfizer — which has, according to one of the leaders of the company’s Analytics and AI Lab, more than 150 AI projects underway — has already accumulated. Tech companies like Alphabet have even more learning; that company had 2700 AI projects underway as far back as 2015.

Admittedly, some steps can be accelerated by waiting if a company is willing to compromise its unique knowledge and ways of conducting business. Vendors are developing a vast variety of knowledge graphs and models that use techniques ranging from natural language processing, to computer vision. If one exists for your industry or business problem, and you’re willing to adopt it with little modification, that will speed up the process of AI adoption. But you may lose your distinctive competence or competitive advantage if you do not tweak it to fit your context and build everything around it.

The obvious implication is that if you want to be successful with AI and think there may be a threat from AI-driven competitors or new entrants, you should start learning now about how to adapt it to your business across multiple different applications and AI methods. Some leading companies have created a centralized AI group to do this at scale. Such central groups focus on framing the problems, proving out the business hypothesis, modularizing the AI assets for reusability, creating techniques to manage the data pipeline, and training across businesses. One other possibility may be to acquire a startup that has accumulated substantial AI capabilities, but there will still be the need to adapt those capabilities to your business. In short, you should get started now if you haven’t already, and hope that it’s not too late.

Microsoft Trending Up, Apple Trending Down…? Plus, The Marriott Data Breach

Youngme Moon, Felix Oberholzer-Gee, and Mihir Desai debate whether Microsoft is trending up while Apple is trending down, before discussing the Marriott (Starwood) data breach. They also share their After Hours picks for the week.

Download this podcast

Some recent picks:

Robert Stavins (follow on Twitter)
FRED (Federal Reserve Economic Data)
RBG (Documentary on Amazon Video)
The Man in the High Castle (Amazon Video)
The Ringer website
Janesville (Amy Goldstein)
Airtable (software)
Small Fry (Lisa Brennan-Jobs)
Educated (Tara Westover)

You can email your comments and ideas for future episodes to: harvardafterhours@gmail.com. You can follow Youngme and Mihir on Twitter at: @YoungmeMoon and @DesaiMihirA.

HBR Presents is a network of podcasts curated by HBR editors, bringing you the best business ideas from the leading minds in management. The views and opinions expressed are solely those of the authors and do not necessarily reflect the official policy or position of Harvard Business Review or its affiliates.

How to Ensure the Success of a Position Your Company Hasn’t Had Before

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According to the World Economic Forum’s 2018 “Future of Jobs” report, many current organizational roles are likely to be disappear as early as 2022, only to be replaced by new organizational roles. You may already be seeing these changes in your organization. Are some roles (in administration perhaps) becoming redundant? Are new roles sprouting up? Does your organization have a data analytics manager yet? How about a social media specialist? A sustainability manager?

Organizations are increasingly hiring people into novel positions, but often struggle to support these new roles. These new roles do not come with a blueprint, nor can they be copied from other organizations. They have to be built from scratch. Too much structure will stifle creativity and innovation. Too much freedom will lead to ambiguity and chaos.

To better understand the tension between control and freedom in new roles, we analyzed more than 4000 pages of interview data, company documents, and media reports from 21 organizations that recently established a “sustainability manager” position and appointed someone to the role. Our research found that organizations vary in how tightly they structure new positions, but they fall into one of three configurations: too tight, too loose, or just right. This last group of organizations are those that found the “Goldilocks fit” between structural controls and employee freedom.

Too loose

Organizations with this configuration have the least formalized commitment to sustainability. These organizations are just starting to consider social and environmental issues. In the absence of formal structures, managers in the new roles scout for social and environmental initiatives that enhance the organization’s reputation, but they can put forward only a very limited range of sustainability initiatives. The managers struggle to access organization resources and have limited discretion. They have trouble explaining their roles to colleagues and feel lost and adrift. They see themselves as a small child, tugging at someone’s trouser leg, asking for more direction and resources, but receiving scant attention.

Too tight

Organizations with this configuration have highly formalized and centralized sustainability programs driven down from the corporate level. In these organizations, the sustainability managers have to justify their activities to their peers in other functional areas (who resist the sustainability programs as another corporate imposition). Sustainability managers’ roles in these organizations are tightly orchestrated with low discretion. When they suggest initiatives, the projects only get a green light if they fit the formal organizational agenda. To avoid being perceived as a bull in a china shop, these managers learn to curb their passion for social and environmental issues and end up feeling disempowered. They constrain their inner “greenies,” even though their organizational role involves going to bat for environmental issues.

Just right

Organizations with this configuration have a broad overall commitment to sustainability, but the specific sustainability initiatives are not rigidly formalized. Sustainability managers in this configuration have considerable discretion to launch and champion innovative social and environmental initiatives. They leverage their discretion to successfully collaborate with internal (i.e., colleagues in other functional areas) and external (i.e., communities and regulators) stakeholders. Sustainability programs are decentralized, so social and environmental initiatives are not viewed as top-down directives but are embedded in the routine activities of other functions. Managers in this configuration feel empowered. They see themselves as music conductors who work with their colleagues to co-create a sustainable future. The sustainability manager in a mining company with this configuration proudly described how he had worked with his colleagues to successfully embed sustainability in the core activities at his organization (e.g., finance, mineral processing, geology). This embedding shifted the sustainability focus of his organization (from “impacting the environment” to a long-term strategic “reliance on the environment”). A manager at a wine company described how she successfully collaborated with stakeholders both within and outside her organization to roll out an environmental assurance program across the entire supply chain.

If new roles are structured too loosely or too tightly, they are unable to provide the best outcomes for their functions. Organizations with these configurations can, over time, evolve to the “just right stage”, but it is not simply a case of natural progression. This evolution demands organizational and managerial maturity and can take decades. If organizations need urgent progress, they can accelerate this transition by deliberately introducing “structural overlays”. Organizations with the too loose configuration (that are fumbling with creating structure around new managerial roles) can consciously incorporate mechanistic overlays. This will give new roles resources, authority and a clear focus to advance specific projects. The too tight organizations can loosen the iron fist of formalization by deliberately introducing organic overlays (such as “sandboxes” for specific projects that demand innovative and collaborative responses). This will temporarily exempt managers from the organizational bureaucracy and give them the freedom to experiment and innovate. Deliberate attention to structural overlays can help organizations fast track their journey towards achieving that “just right” balance between control and freedom in new roles.